Experiences in the management of anastomotic leakages and analysis of the factors affecting leakage healing in patients with esophagogastric junction cancer

Abstract

Background: It was reported in the literatures that the incidence of anastomotic leakage in patients with esophagogastric junction cancer decreased due to application of staplers and closure devices as well as gastric conduit technique in recent years, however, it increased slightly at our center since widely using the above devices and gastric conduit techniques from 2009. The objective of this study was to summarize our experiences in the management of anastomotic leakages and analyze the factors affecting leakage healing in the patients with esophagogastric junction cancer after surgical resection in recent 6 years. Methods: All patients who received surgical resections for esophagogastric junction cancer and diagnosed anastomotic leak at our center between January 2009 and December 2014 were retrospectively analyzed, we also enrolled the patients who had a longer hospital stay (>30 days) as they may develop anastomotic leak. The binary logistic regression in SPSS 16.0 was applied to analyze the factors that may affect leakage healing. Results: Of the 1,815 surgically treated esophagogastric junction cancer patients, 91 cases were diagnosed anastomotic leakage postoperatively. The patients were divided into two groups based on the median leakage healing time (40 days) in this series: fast healing group (37 cases) and slowly healing group (54 cases). All factors that may affect the leakage healing were put into analysis by using binary logistic regression. The results of the analysis showed that leakage size (OR =1.073, P=0.004), thoracic drainage (OR =12.937, P=0.037) and smoking index ≤400 (OR =1.001, P=0.04) significantly affected the healing time, while drinking history (P=0.177), duration of fever after anastomotic leak developed (P=0.084), and hypoproteinemia after leak (P=0.169) also apparently but not significantly affect the healing time.Conclusions: Though many factors may affect leakage healing in the esophagogastric junction carcinoma patients, leakage size, thoracic drainage and smoking index (≤400) are the most important factors affecting the leakage healing. Placement of a chest tube beside the anastomosis area during operation for early identification and control of an anastomotic leak to minimize contamination of the mediastinum is the most important way to promote leakage healing. A chest tube placing into the purulent cavities after the patients experienced leaks is also important for the cure of leakage. More attention should be paid perioperatively to the patients who had a smoking index (≥400) and the patients who suffered fever or hypoproteinemia.

Comparative Study of Early Postoperative Complications: Thoracic Anastomosis vs Cervical Anastomosis - in Esophageal Replacement with Gastric Graft

“…The difference in values between AL rates for cervical anastomosis and thoracic anastomosis are well documented. The suggested explanations for a higher rate of cervical AL are 1) the reduced blood supply available in the cervical region, 2) high anastomotic tension in a short gastric graft, 3) lack of protective tissue with rich blood supply, 4) low protein levels, especially albumin, and 5) anemia (13). International studies have demonstrated the correlation between mortality rate and the presence of an AL, a correlation not present in our study, most likely due to the small number of patients involved.…”

Early detection of complications: anastomotic leakage

“…Grade 4 (conduit necrosis) is diagnosed by endoscopy. The following points should be considered when diagnosing AL because diagnosis and treatment of AL differ based on the variety of the disease (21,22,25). First, AL should be confirmed and classified simultaneously (21,22).…”

“…The drainage of bile, enteric content, saliva, or air via a surgically positioned drain adjacent to the anastomosis indicates a possible AL (12,14,24). With early diagnosis and treatment of AL, a tube adjacent to the anastomotic stoma can be placed at the time of surgery (22,25,39). The methylene blue swallow test is a simple and convenient method of identification-immediate discoloration of the drain will be observed after swallowing methylene blue-and is usually used for bedside diagnosis (22,31).…”

Enforced smoking cessation programme prior to elective surgery

“…In general surgery, smoking significantly increases the risk of developing wound complications, including post‐laparotomy incisional hernia, or even death post elective hernia repair . In colorectal surgery, the risk of anastomotic leakage is considerably increased, and comparable negative results have also been reported following surgical excision of oesophagogastric junction cancer or after liver resection . Finally, smoking has been shown to be an independent factor for wound complications and extended length of post‐operative hospital stay following laparoscopic cholecystectomy …”

“…5 In colorectal surgery, the risk of anastomotic leakage is considerably increased, 6 and comparable negative results have also been reported following surgical excision of oesophagogastric junction cancer or after liver resection. 7,8 Finally, smoking has been shown to be an independent factor for wound complications and extended length of post-operative hospital stay following laparoscopic cholecystectomy. 9 There is strong evidence that managing nicotine dependence, and providing perioperative smoking cessation advice and support to smokers following the 5As approach, is an effective long-term strategy, as shown by the U.S. Department of Health and Human Services.…”